Workplace Violence

“You took my money, you son of a b****!” The first punch caught me in the temple and I quickly raised my hands to protect my head and glasses from the flurry of blows that followed. Struggling to my feet, I pushed him back and we both fell through the doorway into the hall, with him still trying to get some in some punches and me trying to grab his hands. Luckily Donnie heard the commotion and came running to my assistance. We pinned my assailant to the floor, holding his arms and legs while the nurse injected a sedative. Then one on each arm we hauled him to his feet and frog-marched him across the ward to the “therapeutic quiet” room – an empty, windowless room where violent patients could be kept under observation until they cooled down.

To be fair, I had taken his money. Although it was only 930 am, he was the second admission of the day to the regional psychiatric hospital. In the midst of some substance-induced psychotic break, he had been taken to the hospital by the RCMP arriving at the hospital in handcuffs and leg manacles – a sure sign that there had been trouble along the way. I met him at the door and shepherded him through the admission process; swapping street clothes for pajamas and a housecoat, assigning him to a bed in the admission ward and, of course, making sure that his money and valuables were itemized and sent to the business office for safekeeping.

I worked on the male admission ward – approximately 50 patients at any given time with a mix of new admissions, long term residents and geriatrics. I worked in a position that I don’t think exists anymore – a nursing attendant- part personal care worker and part security guard. A typical shift would consist of two nurses, two CNAs (now called LPNs) and two or three nursing attendants. In a strange staffing calculus, we also had to monitor the number of “men” on the shift – hospital rules insisted on at least two male staff on the floor at all times (all nursing attendants on the floor were male, nurses and CNAs could be either male or female)– a blunt recognition that workplace violence was, in this environment, a part of the job.

Although in many ways those were the “bad old days” of psychiatric care, we did get that one thing right. In an environment where violence was a persistent hazard, you treated it that way. You assessed the risks and put procedures in place to mitigate the risks. We ensured that there were always sufficient staff to deal with a crisis. An emergency alarm system was in place to draw assistance from other areas of the hospital if needed. Staff worked in pairs when going into unpredictable situations and the potential for violence was carefully monitored.

The reality is for many people – and not always the ones you expect – violence is part of the job. It is a known and predictable workplace hazard. If you work alone, at night or on weekends, if you deal with valuables (including alcohol and tobacco), if you have authority over others and/or are in a position to deny services or requests, or if you are responsible for providing care to others, then your job has an increased risk of workplace violence[1][2] Nurses and health care providers, counsellors, social service workers, prison guards and teachers are all occupations where violence is a known and predictable risk. Unlike police and the military, most people in these occupations are not provided with the training, support or Kevlar vests to deal with a violent assault.

Organizational responses are often misdirected, perhaps because they are frequently based on a number of myths about workplace violence[3]. The most persistent of these seems to be that it is our coworkers (the mythical disgruntled employee) that we need to fear. As a result, a “zero tolerance” policy aimed at employees is the most common response to workplace violence.

The data are absolutely clear. Most workplace violence is perpetrated by people who are committing another crime (e.g., a robbery) or are not in a position to appreciate that their actions are criminal (i.e., they are very young, in a great deal of distress, are not in touch with reality, etc.). None of these people particularly cares what your policy says. My guess is that in the extremely rare instance where one of your coworkers decides to risk a prison sentence by physically attacking you, s/he is probably not too worried about the corporate policy either.

An occupational health and safety approach to workplace violence holds more promise. One begins with an understanding of the situational and imminent risks of workplace violence and then implements procedures to eliminate or mitigate those risks[4]. Situational risks are those that derive from the nature of the work (e.g., providing care, denying a service). Within the broader situation there are often cues that signal that violence is imminent (individuals who are swearing, agitated, loud or uttering threats). Understanding these risks allows us to put security protocols in place and, just as importantly, knowing when to invoke the security procedures.

Mitigating risk means both decreasing the risk and minimizing the adverse effects of workplace violence. Training staff in de-escalation procedure and how to assess risk can reduce or eliminate many violent situations. As my experience in the hospital indicates, effective mitigation is often rooted in staffing decisions – ensuring that there are enough staff available to head off, or deal with, any crisis. That is not a popular message in many organizations. Nonetheless, it is one that needs to be heard.